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Generally a th cus infection i throat, so that tion is presen nesses, includ disease. Skill 2 throat culture Laborator Arterial Bloo Arterial blood than a vein as used arteries plastic syringe heparin adde blood from cl After testin fessional inser angle. Unlike o for ABGs. Inste causes the plu syringe. After the n health-care p additional air

DavisPlus, located at http://davisplus.fadavis.com. OXYGENATION STATUS. When beginning to assess the pa- tient’s oxygenation status, determine the patient’s orientation to time, place, and person. Note restlessness and unusual irritability or confusion. Even minor changes can indicate hypoxia. Safety: Remember that changes in level of conscious- ness can indicate decreased oxygen reaching the brain. OXYGEN SATURATION. Determine oxygen saturation using a pulse oximeter. (Refer to Chapter 17 for the procedure for using pulse oximetry.) The pulse oximeter is used to measure the oxygen saturation of capillary blood (SaO 2 ). The normal range for SAO 2 is 95% to 100%. In healthy people, a satura- tion of 94% or below is cause for concern. Safety: Remember that nail polish, especially a dark color, and artificial nails will cause inaccurate pulse oximetry results. Remove nail polish or use an alternative site such as the earlobe or forehead. You can check a patient’s oxygen saturation without a health-care provider’s order. Be alert to subtle signs and symptoms of hypoxemia, and check the oxygen saturation when indicated.

TEXT STEP #1 Build a solid foundation.

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UNIT FOUR

582

Clinical Skills and Care

Clinical Skills and Care Critical Thinking Connections at the beginning of every chapter help connect what you read to what you will see and do in the clinical setting. The diaphragm and the intercostals are the muscles re- quired for breathing to occur. When the diaphragm contracts in response to stimulus from the phrenic nerves, it moves downward, which increases the size of the chest cavity. In- tercostal muscles then contract, moving the ribs up and out, which also enlarges the chest cavity from side to side and from front to back. When the chest cavity size increases, it causes the lungs to expand. The pressure within the lungs then drops below atmospheric pressure, or becomes negative pressure. This causes a sort of vacuum; air is pulled into the lungs until the pressure in the lungs equals the pressure out- side of the body. The term used to describe this is inhalation, also known as inspiration. and carbon dioxide move across the alveolar cell membranes and the cell membranes of the capillaries surrounding the alveoli by the process of diffusion. This process occurs involuntarily, meaning that no con- scious thought is given to it. It is important to understand the mechanics of how breathing occurs so that you can grasp the treatments for respiratory disorders affecting those mechan- ics, such as chest tubes, endotracheal tubes, and mechanical ventilation. Sample Documentation Regulation of Respiration Nerves and a chemical control mechanism both contribute to the regulation of respirations. The respiratory center is in the medulla, located in the brainstem. This brain function automatically controls inhalation by sending impulses to the phrenic nerve, which causes contraction of the diaphragm and intercostal muscles. As these muscles relax, again in response to nerve stimu- lus, the size of the chest cavity decreases. The ribs come in- ward, the diaphragm rises upward, and the lungs are then compressed, forcing the air to go out. This is referred to as exhalation, also known as expiration. Chemical regulation of respirations is influenced by chemoreceptors located in the carotid and aortic bodies and in the medulla of the brain. When these chemoreceptors de- tect a decrease in the oxygen level of the blood or a change in blood pH, they send a message to the medulla, which in turn causes an increase in the rate and depth of respirations. When carbon dioxide increases above normal amounts, it causes the blood to become more acidic. The chemorecep- tors respond by sending the message to the medulla, which in turn causes the respiratory rate to increase to “blow off” or remove excess carbon dioxide, returning the blood pH to normal levels. (See Chapter 29 for more information about acid-base balance and the role of the lungs in maintaining blood pH.) Rising carbon dioxide levels that in turn cause the blood to become more acidic provide the brain’s stimulus to breathe.

SKILLS—cont’d

28.4 Administering a Nebulizer Treatment 28.5 Administering Supplemental Oxygen 28.6 Performing Nasopharyngeal and Oropharyngeal Suctioning 28.7 Performing Endotracheal and Tracheostomy Suctioning 28.8 Performing Tracheostomy Care 28.9 Maintaining Chest Tubes

KNOWLEDGE CONNECTION What areas will you inspect when assessing a patient with impaired oxygenation? When you palpate, what two evalu- ations are you making? How can you tell if the patient is becoming hypoxic or hypoxemic?

Knowledge Connection boxes check your understanding of the material you just read.

CRITICAL THINKING CONNECTION Clinical Assignment

588 You are assigned to care for a hospitalized patient tomorrow in clinical who has a tracheostomy. He was injured in a car accident and was on a ventilator for several weeks. He is breathing on his own now, but he still has the tracheostomy in place. In addition, he has recently developed pneumonia in his right lung. He has a large amount of secretions and requires suctioning every 2 to 3 hours. The tracheostomy will have to be

UNIT FOUR

Skill 28.9 (continued) 10. Ensure that Vaseline and gauze 4 × 4s are at the bedside in case of air leakage or other emergency. Follow your facility’s policy for appropriate action to take if the chest tube is dislodged. 11. Assess output in the collection chamber. Be aware of the color and amount draining each hour. Safety: Notify the phy- sician immediately if the drainage changes to a bright red color or is greater than 100 mL/hr. 12. Assess for air leaks in the drainage system. Remember that wet suction will bubble gently in the suction chamber. If the patient has a pneumothorax, expect to see air in the water- seal chamber and tidaling in the chamber. As the pneu- mothorax resolves and the lung reinflates, the air in the water-seal chamber and the tidaling in the chamber will cease. 13. Mark output for your shift on the writable surface of the col- lection chamber. Mark the level of the output and then write the date, time, and your initials. Calculate drainage out- put for your shift by subtracting the amount in the drainage chamber when you started your shift from the amount in the chamber at the end of your shift. 14. Assist the patient to a comfortable position and reassure them regarding the chest tubes. Encourage the patient to change position, cough, and deep breathe every 2 hours to help re-expand the lung and remove drainage from the chest cavity. 15. Follow the Ending Implementation Steps located on the inside back cover.

Evaluation Steps 1. Evaluate the effectiveness of the chest tubes. Is the patient breathing with less difficulty? Is the suction set correctly? Is the water seal at 2 cm of water? Are there signs of escaping pneumothorax? Are there any signs of additional air leaks? 2. Evaluate the patient’s response to the procedure. Is the patient resting comfortably? Is pain medication needed for the incision site? Is the patient complaining of any other problems? 3. Evaluate the insertion site dressings. If there is a hemothorax, is the dressing dry and intact? Does it need to be reinforced or changed? Follow your facility’s policy for changing the dress- ing to the chest tube insertion site.

• Encou ease p one p of res • Encou • Urge becau ing it • Expla groun • Tell p to be matio • Expla matio are sit

cleaned on your shift and a new inner cannula put in place. He has humidified oxygen at 4 L/min via a tracheostomy collar. Critical Thinking Questions: 1. Why is a tracheostomy done? 2. How does a tracheostomy work? 3. How will you suction it? 4. How will you clean it and replace the inner cannula? 5. What is a tracheostomy collar?

Older Adult Connection Teaching Older Adults Have a caregiver or family member present during teaching, if possible. Allow plenty of time for teaching so that the patient does not feel rushed. Be alert to cues that the older patient does not understand the teaching. They may put you off, saying, “I’ll do it later” or “I already read it.” This may occur because the patient is confused or does not understand but does not want to say so. Be very patient with older adult learners. Use plenty of repetition without getting frustrated. 10/12/28 1825 Dr. Chapman inserted one chest tube for hemothorax. Attached to Pleuravac drainage system with wet suction at –20 cm. Water seal established with 2 cm water. Chest tube draining mod amt of dark red fluid, less than 100 mL/hr. All connections double-taped. Drsg at insertion site clean, dry, and intact. Resting quietly in bed in semi-Fowler’s position eating ice chips. States he “can breathe better” after chest tube insertion. Requests pain med for incisional pain. _________________________________________________________________________ ___________________________________________________ Nurse’s signature and credentials Settings Connection: Home Health Home Health Referral for Teaching Patients who are to be discharged from the hospital but need more teaching can be referred to home health care for follow-up teaching. This requires a health-care provider’s order. Be alert to the need to ask for a referral for more teaching. A home health-care follow-up often can prevent rehospitalization if the patient has not mastered information needed for self-care. your patient and made him a little short of breath. How- ever, once you had suctioned his tracheostomy several times, he could breathe considerably better and mouthed “thank you.” After that, you weren’t afraid to suction him. His tracheostomy collar stayed in place pretty well, and you were able to replace his inner cannula the first day with your instructor’s guidance. By the second day, you were feeling far more confident about all of his care. By the third day of clinicals, you were showing other students how to suction him.

Geriatric content throughout familiarizes you with this important patient demographic.

or pro source doubt can be quick pharm Encou inform tinue notify home

CRITICAL THINKING CONNECTIONS: POST CONFERENCE

Critical Thinking Connections: Post Conference boxes at the end of every chapter provide answers to the questions posed by the Critical Thinking Connections. NORMAL OXYGENATION

You were really worried when you walked into your patient’s room the first morning and saw him with his tra- cheostomy, sounding all bubbly and coughing frequently. He pointed to the tracheostomy and mouthed the word “suction.”Without much time to think, you grabbed a suc- tion catheter and glove kit and set up quickly but with- out contaminating your sterile field or sterile supplies. You remembered as you suctioned to hold your own breath and not suction for longer than 10 seconds. It was obvious to you that the suctioning procedure tired Key Points • Muscles, nerves, and chemicals all play a role in causing and controlling respirations. • Impaired oxygenation may be the result of hypoxia or

The term airway refers to the path that air takes as it enters and exits the lungs. The normal pathway is through the nos- trils into the pharynx, into the trachea, and then to either the right or the left bronchus, which branches into the bronchi- oles that terminate into the alveoli. When this pathway is un- blocked and air is moving freely, it is referred to as a patent airway. The Mechanics of Breathing When the airway is patent, air is inhaled and follows the path- way to the alveoli, where oxygen is absorbed into the blood and carbon dioxide leaves the blood to be exhaled. Oxygen

• Give

• WORD • BUILDING • inhalation: in – in + hala – breath + tion – action exhalation: ex – out + hala – breath + tion – action

• Crepitus indicates air under the skin, or subcutaneous emphysema, and the source of the leaking air must be found and treated.

the most e ff ective way to break the chain of infection? When can alcohol-based hand gels be used for hand hygiene? When can they not be used?

and

ial nails are

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and gels aring for

602 Evidence-Based Practice Ventilator-Associated Pneumonia in Acute Care Hospitals Clinical Question UNIT FOUR Skill 28.2 (continued) Do patients have a higher risk for ventilator-associated pneumonia (VAP) who receive mechanical ventilation (MV)? Evidence Patients who receive MV are at a higher risk for nosocomial pneumonia. VAP is a type of HAI. A patient is at risk for VAP if they are on MV for 13 to 51 per 1,000 ventilator days. A patient is also at risk for developing MRSA while on me- chanical ventilation. When the patient must be frequently

shed the uidelines 14.2 pro-

Clinical Skills and Care

8. Carefully replace the swab into the sterile tube. Contamina- tion of the swab or tube can lead to misdiagnosis and inappropriate treatment for the patient. 9. Crush the capsule in the end of the tube to provide a moist environment for the pathogens until the culture is done. 10. Label the tube according to facility policy. 11. Follow the Ending Implementation Steps located on the in- side back cover. Evaluation Steps 1. Ensure that an adequate specimen has been taken so that the culture will grow any pathogens present in the patient’s throat.

2. Evaluate the patient’s tolerance of the procedure. Did it cause gagging or throat discomfort? 3. Ensure that the throat culture tube is placed in the appropri- ate biohazard specimen bag with the requisition and taken to the laboratory.

Evidence-Based Practice boxes demonstrate the link between research and practice that underlies the best nursing care.

Sample Documentation

ows are

10/10/22 1330 Throat culture obtained per order and delivered to the lab. Pharynx red with yellowish-white patches noted on tonsils bilaterally. Culture taken from these areas. C/o sore throat before and after procedure. Nurse’s signature and credentials

Skill 28.3 Assisting With Incentive Spirometry

Assessment Steps 1. Verify the health-care provider’s order for incentive spirome- try. Note: Some hospitals do not require a health-care provider’s order for this because it is considered a nursing or respiratory therapy order. Always follow your facility’s policy. 2. Determine the patient’s pain level, availability, and willing- ness to perform the procedure. It may be necessary to med- icate the patient for pain before beginning the procedure. Planning Steps 1. Obtain an incentive spirometer. 2. Plan for appropriate time for incentive spirometry; avoid mealtimes. Implementation Steps 1. Follow the Initial Implementation Steps located on the inside front cover. 2. Assist the patient to an upright position in the bed or chair to enlarge the rib cage and allow for maximum lung expansion. 3. Splint abdominal or chest incisions with a pillow to prevent pain during deep inhalation and exhalation. 4. Place the mouthpiece of the incentive spirometer between the patient’s lips to prevent air from escaping around it during inhalation. 5. Instruct the patient to take a deep breath through the mouth, then exhale through the nose. This helps the patient understand that the focus is on deep inhalation, not exhalation.

Step-by-step procedures for over 120 skills make every concept easy to grasp.

6. Show the patient how far the platform or balls moved. Identify the goal for the patient to work toward. Set the slide pointer to the goal volume on the spirometer. 7. Instruct the patient to repeat the inhalations 10 times every hour while awake to prevent respiratory complications of immobility such as pneumonia and atelectasis. 8. Follow the Ending Implementation Steps located on the inside back cover. Evaluation Steps 1. Ask the patient to demonstrate the use of the incentive spirometer without verbal cues to ensure that he or she understands how to correctly use it. 2. Check back frequently to be sure the patient is using the incentive spirometer as ordered.

Sample Documentation

10/10/22 1100 Assisted with incentive spirometry. Able to raise 2 out of 3 balls in unit. Instructed to repeat 10 times each hour. Nurse’s signature and credentials

CLINICAL JUDGMENT IN ACTION Scenario: You are a nursing student at a long-term care facility for basic nursing clinical experience. As you walk past a resident’s door, you see him getting up from a chair without his walker and taking a very unsteady step away from the chair. This is a situation where you must use your clinical judgment and act quickly. • What are the cues in this situation? • What is your hypothesis when you analyze these cues? • What action will you take? • How will you evaluate the effectiveness of your action?

Clinical Judgment in Action boxes ask you to consider the current situation, prioritize and describe the actions you would take, and explain why.

LEARN

STEP #2 Make the connections to key topics.

UNIT THREE

216

Nursing Basics

Another step in identifying which coccus, bacillus, or spi- rillum is under the microscope involves using a dark purple stain called a Gram stain. The slide containing the microor- ganism is  ooded with Gram stain and then rinsed with alco- hol. It is counterstained with safranin and then rinsed with water. When the slide is viewed under the microscope again, the bacteria will have taken up the stain. Those that appear either purple or blue are known as gram-positive organisms. Those that appear pink or red are identi  ed as gram-negative organisms. The amount and type of stain the bacterium retains is dependent on the composition of its cell wall. Different medications are most effective for different types of organ- isms and are prescribed based on their Gram stain response. Rickettsia are a type of bacteria, but they are different from most because they can only reproduce inside the cells of the host, similar to the way viruses must reproduce. Rick- ettsia are often spread through the bites of insects, such as ticks and mites, which are called vectors. The insects are carriers of the microorganisms, and when they bite a human, the human becomes ill as a result of infection from the rick- ettsia bacteria. Antibiotics are prescribed to treat infections caused by bacteria. There are many types of antibiotics, and each acts in a slightly different way to kill bacteria. (For more infor- mation about antibiotics and their actions, see Chapter 35.) It is important to note that antibiotics are effective against most bacteria. Multiple-drug-resistant organisms, also called MDROs, are bacteria that have mutated in such a way that they are resistant to many of the antibiotics normally used to treat infections. Examples of MDROs are MRSA, vancomycin-resistant enterococcus (VRE), and Clostrid- ioides dif  cile, also called C. diff. Infections with these organisms are particularly dif  cult to resolve because of their antibiotic resistance. Only a few antibiotics are effective against each of them. is examined under a microscope, the medical laboratory technologist identifies the bacterium by its shape (Fig. 14.1). Cocci ( singular coccus) are sphere-shaped bacteria. Sometimes they may be seen in clusters and are similar to grapes in appearance. These are known as staphylococci. They may also appear in chains, like a bead necklace, and are then referred to as streptococci. Or they may appear in pairs, like two balls side by side, which are described as diplococci. Bacilli (singular bacillus) are rod-shaped bacteria. They have a log-like appearance and may vary in length. Spirilla (singular spirillum) are long cells that spiral or coil, similar to a curl of long hair.

When you work in a hospital as a student or as a staff nurse, you are surrounded by some virulent germs. This can be very alarming if you do not understand the causes of infection or do not know how to protect yourself and your patients from disease-causing microorganisms. In this chapter, you will learn how to protect yourself and how to prevent the spread of disease-causing germs to other patients or your family. CAUSES OF INFECTION Infections are caused by a variety of microorganisms. These are minuscule living bodies that cannot be seen with- out a microscope. Microorganisms that cause infection in humans are referred to as pathogens. They reproduce rap- idly and can spread from one area of a person’s body to another. Not all microorganisms are pathogenic, however. Many microorganisms live in and on our bodies, performing needed functions to protect us from harmful pathogens and helping us break down and digest food. These microorgan- isms are referred to as normal  ora. Types of Pathogens Pathogenic microorganisms are classi  ed as bacteria, viruses, protozoa, fungi, or helminths. Bacteria Bacteria are one-celled microorganisms found virtually everywhere, including in the human body. It is only when they invade an area outside their normal location that prob- lems result. For example, several bacteria live in the intes- tines to help the body digest food and absorb vitamins. They belong there. However, if those particular bacteria are intro- duced into the urethra and migrate to the bladder, they could cause a urinary tract infection. The most common bacteria are Staphylococcus aureus. CRITICAL THINKING CONNECTION—cont’d because you are worried that you might catch the infection or take the microorganism home to your children. Critical Thinking Questions 1. What is MRSA? 2. What precautions would you use before entering the patient’s room? 3. What treatment will you expect to be ordered for this patient? Laboratory and Diagnostic Connection Identifying Bacteria in the Laboratory Bacteria are named and classified by their shape. A specimen of drainage, sputum, stool, urine, or blood is obtained and sent to the laboratory. When the specimen

CHAPTER 14 Medical Asepsis and Infection Control

KEY TERMS

LEARNING OUTCOMES

1. Define various terms related to medical asepsis and infection control. 2. Describe five types of pathogens. 3. Identify selected common illnesses caused by microbes. 4. Illustrate the chain of infection. 5. Differentiate types of infections. 6. Compare primary, secondary, and tertiary defenses against infection. 7. Explain factors that decrease the body’s defenses. 8. Differentiate between the use of standard precautions and transmission-based precautions. 9. Compare the purposes and types of transmission-based precautions. 10. Compare medical and surgical asepsis. 11. Explain nursing responsibilities for cleaning the environment and equipment. 12. Describe when and how to use hand hygiene. 13. Detail the use of standard precautions. 14. Explain ways to meet the emotional needs of patients who are isolated because of communicable disease. 15. Discuss information in the Connection features in the chapter. 16. Identify safety issues related to medical asepsis and infection control. 17. Answer questions about performing the skills in this chapter.

Chain of infection (CHAYN uv in-FEK-shun) Direct contact (dih-REKT KON-takt) Disinfectant (DISS-in-FEK-tent) Health-care–associated infection (HELLTH- KARE-a-SOH-see-ayt-ed in-FEK-shun) Indirect contact (IN-dih-rekt KON-takt) Localized infection (LOH-kuh-LYEZD in-FEK- shun) Medical asepsis (MED-ih-kuhl ay-SEP-siss) Microorganism (MY-kroh-OR-gan-izm) Normal flora (NOR-mal FLOR-ah) Pathogen (PATH-oh-jen) Primary infection (PRY-mare-ee in-FEK-shun) Secondary infection (SEK-un-DARE-ee in-FEK- shun) Standard precautions (STAN-derd prih-KAW- shuns) Systemic infection (sis-TEM-ik in-FEK-shun) Transmission-based precautions (trans-MIH- shun BAYST prih-KAW-shuns) Vector (VEK-tur)

Infection Prevention & Control

CHAPTER CONCEPTS

Infection Safety Immunity Caring Evidence-Based Practice

SKILLS

Infection Prevention & Control

14.1 Performing Hand Hygiene 14.2 Donning Personal Protective Equipment 14.3 Removing Personal Protective Equipment

CRITICAL THINKING CONNECTION Clinical Assignment

You are assigned to care for a 38-year-old male patient who has an infection caused by methicillin-resistant Staphylococcus aureus (MRSA). You know this is a highly contagious infection that is resis- tant to many antibiotics. It frightens you to care for this patient

Continued

• WORD • BUILDING • microorganism: micro – small + organism – life form pathogen: patho – disease + gen – producer

215

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Assignments in Davis Advantage correspond to key topics in your book. Begin by reading from your printed text or click the eBook button to be taken to the FREE, integrated eBook.

Pre-Assessment for Medical Asepsis and Infection Control

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Question 2 of 6 A patient is asking the nurse about multiple-drug-resistant microorganisms. Which microorganisms are considered multiple-drug-resistant? Select all that apply. MRSA VRE Trichomonas vaginalis Rickettsia rickettsii Clostridioides difficile

Pre-Assessment for Medical Asepsis and Infection Control

Following your reading, take the Pre-Assessment quiz to evaluate your understanding of the content. Questions feature single answer, multiple-choice, and select-all-that-apply formats.

Online content subject to change upon publication.

Medical Asepsis and Infection Control

After working through the video and activity, a Post-Assessment quiz tests your mastery.

Animated mini-lecture videos make key concepts easier to understand, while interactive learning activities allow you to expand your knowledge and make the connections to important topics.

Post-Assessment for Medical Asepsis and Infection Control

Question 2 of 6 In which situation would standard precautions be adequate? Select all that apply. While talking with a patient diagnosed with measles While assisting a patient with oral care While ambulating a patient after a procedure While inserting an intravenous catheter When changing a dressing for a patient with MRSA

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Fundamentals

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Medical Asepsis and Infection Control Chapter 14 Vital Signs Chapter 17 Physical Assessment Chapter 21 Surgical Asepsis Chapter 22 Respiratory Care Chapter 28 Fluids, Electrolytes, and Introduction to Acid-Base Chapter 29

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Medical Asepsis and Infection Control

Real-world cases mirror the complex clinical challenges you will encounter in a variety of healthcare settings. Each case study begins with a patient photograph and a brief introduction to the scenario.

The Patient Chart displays tabs for History & Physical Assessment, Nurses’ Notes, Vital Signs, and Laboratory Results. As you progress through the case, the chart expands and populates with additional data.

Medical Asepsis and Infection Control

Complex questions that mirror the format of the Next Gen NCLEX® require careful analysis, synthesis of the data, and multi-step thinking.

Medical Asepsis and Infection Control

Immediate feedback with detailed rationales encourages you to consider what data is important and how to prioritize the information, resulting in safe and effective nursing care.

You answered 2 out of 6 questions correctly.

Test-taking tips provide important context and

225-226

strategies for how to consider the structure of each question type when answering.

ASSESS STEP #4 Improve comprehension & retention. High-quality questions , including more difficult question types like select-all-that-apply , assess your understanding and challenge you to think at a higher cognitive level. PLUS! Brand-new Next Gen NCLEX ® stand-alone questions provide you with even more practice answering the new item types and help build your confidence.

Medical Asepsis and Infection Control

Comprehensive rationales explain why your responses are correct or incorrect. Page-specific references direct you to the relevant content in your text, while Test-Taking Tips improve your test-taking skills.

Create your own practice quizzes to focus on topic areas where you are struggling, or use as a study tool to review for an upcoming exam.

Physical Assessment

Clinical Judgment

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Brief Contents UNIT ONE: Introduction to Nursing, 1 1 The Vista of Nursing, 1 2 Health-Care Delivery, Settings, and Economics, 14 3 Ethics, Law, and Delegation in Nursing, 28 4 The Nursing Process: Critical Thinking, Decision Making, and Clinical Judgment 43 5 Documentation, 70 6 Communication and Relationships, 98 7 Promoting Health and Wellness, 116 8 Ethnic, Cultural, and Spiritual Aspects of Care, 127 9 Growth and Development Throughout the Life Span, 138 10 Loss, Grief, and Dying, 157 11 Complementary and Alternative Medicine, 176 12 Patient Teaching, 187 UNIT THREE: Nursing Basics, 196 13 Safety, 196 14 Medical Asepsis and Infection Control, 215 15 Personal Care, 237 16 Moving and Positioning Patients, 271 17 Vital Signs, 302 18 Applying Heat and Cold Therapies, 335 19 Pain Management, Rest, and Restorative Sleep, 348 20 Admission, Transfer, and Discharge, 363 21 Physical Assessment, 376 22 Surgical Asepsis, 409 UNIT TWO: Communicating and Understanding, 98

UNIT FOUR: Clinical Skills and Care, 426 23 Nutrition, 426 24 Nutritional Care and Support, 445 25 Diagnostic Tests, 485 26 Wound Care, 504 27 Musculoskeletal Care, 539 28 Respiratory Care, 556 29 Fluids, Electrolytes, and Introduction to Acid – Base Balance, 590 30 Bowel Elimination and Care, 611 31 Urinary Elimination and Care, 642 32 Care of Older Adults, 677 33 Care of the Surgical Patient, 701 34 Phlebotomy and Blood Specimens, 735 UNIT FIVE: Medication Administration, 754 35 Researching and Preparing Medications, 754 36 Administering Oral, Topical, and Mucosal Medications, 774 37 Administering Intradermal, Subcutaneous, and Intramuscular Injections, 800 38 Intravenous Therapy, 831 Appendix A: Photo and Illustration Credits for Unnumbered Figures, 906 Glossary, 908 Index, 922

CHAPTER 28 Respiratory Care

KEY TERMS

LEARNING OUTCOMES

Crepitus (KREP-ih-tuss) Cyanosis (SYE-uh-NOH-siss) Endotracheal tube (EN-doh-TRAY-kee-uhl TOOB) Exhalation (EKS-ha-LAY-shun) Hemothorax (HEE-moh-THAW-raks) Hypoxemia (HYE-pok-SEE-mee-ah) Hypoxia (hye-POK-see-ah) Incentive spirometer (in-SEN-tiv spye-ROM-uh-tur)

1. Define various terms associated with respiratory care. 2. Explain the mechanics of inhalation and exhalation. 3. Describe chemical and nervous regulation of respirations. 4. Explain the changes in physiological regulation of respiration in patients with chronic lung disease. 5. Differentiate between internal and external respiration. 6. Contrast hypoxia and hypoxemia. 7. Identify causes of impaired oxygenation. 8. List inspection points in the assessment of a patient with impaired oxygenation. 9. Describe palpation, auscultation, and other assessment findings that could indicate impaired oxygenation. 10. Discuss the significance of selected diagnostic tests when caring for patients with impaired oxygenation. 11. Explain nursing interventions to use for patients with impaired oxygenation. 12. Discuss safety measures to enforce when the patient is receiving supplemental oxygen. 13. Identify types of oxygen sources and delivery devices used for supplemental oxygen. 14. List tips for conservation of energy for patients with chronic lung disease. 15. Describe various artificial airways and how to suction the patient with the airway in place. 16. Describe a tracheostomy tube and the nursing care needed to keep it patent. 17. Illustrate chest tube placement and how the chest drainage system works. 18. Discuss nursing care of patients with chest tubes. 19. Plan care for a patient with a respiratory disorder. 20. Discuss information found in the Connection features of the chapter.

Inhalation (IN-hah-LAY-shun) Nebulizer (NEB-yoo-LYE-zer)

Parietal pleura (pah-RYE-et-uhl PLOO-rah) Pleural effusion (PLOOR-uhl ef-YOO-zhun) Pneumothorax (NEW-moh-THAW-raks) Sputum (SPYOO-tum) Tension pneumothorax (TEN-shun NEW-moh-THAW-raks) Tracheostomy (TRAY-kee-AWS-tuh-mee) Visceral pleura (VISS-uh-ruhl PLOO-rah)

CHAPTER CONCEPTS

Acid–Base Caring Clinical Judgment Oxygenation Perfusion Safety Stress and Coping Teaching and Learning

21. Identify safety issues related to respiratory care. 22. Answer questions about skills in the chapter.

SKILLS

28.1 Obtaining a Sputum Specimen 28.2 Obtaining a Throat Culture Specimen 28.3 Assisting With Incentive Spirometry

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Oxygen and carbon dioxide move across the alveolar cell membranes and the cell membranes of the capillaries surrounding the alveoli by the process of diffusion. This process occurs involuntarily, meaning that no con- scious thought is given to it. It is important to understand the mechanics of how breathing occurs so that you can grasp the treatments for respiratory disorders affecting those mechan- ics, such as chest tubes, endotracheal tubes, and mechani- cal ventilation. The diaphragm and the intercostals are the muscles required for breathing to occur. When the diaphragm con- tracts in response to stimulus from the phrenic nerves, it moves downward, which increases the size of the chest cav- ity. Intercostal muscles then contract, moving the ribs up and out, which also enlarges the chest cavity from side to side and from front to back. When the chest cavity size increases, it causes the lungs to expand. The pressure within the lungs then drops below atmospheric pressure, or becomes negative pressure. This causes a sort of vacuum; air is pulled into the lungs until the pressure in the lungs equals the pressure out- side the body. The term used to describe this is inhalation, also known as inspiration. As these muscles relax, again in response to nerve stim- ulus, the size of the chest cavity decreases. The ribs come inward, the diaphragm rises upward, and the lungs are then compressed, forcing the air to go out. This is referred to as exhalation, also known as expiration. Regulation of Respiration Nerves and a chemical control mechanism both contribute to the regulation of respirations. The respiratory center is in the medulla, located in the brainstem. This brain function automatically controls inhalation by sending impulses to the phrenic nerve, which causes contraction of the diaphragm and intercostal muscles. Chemical regulation of respirations is in fl uenced by che- moreceptors located in the carotid and aortic bodies and in the medulla of the brain. When these chemoreceptors detect a decrease in the oxygen level of the blood or a change in blood pH, they send a message to the medulla, which in turn causes an increase in the rate and depth of respirations. When car- bon dioxide increases above normal amounts, it causes the blood to become more acidic. The chemoreceptors respond by sending the message to the medulla, which in turn causes the respiratory rate to increase to “blow off,” or remove, excess carbon dioxide, returning the blood pH to normal lev- els. (See Chapter 29 for more information about acid–base balance and the role of the lungs in maintaining blood pH.) Rising carbon dioxide levels that in turn cause the blood to become more acidic provide the brain’s stimulus to breathe. That is why you cannot hold your breath for long periods— not because your oxygen level is falling, but because you are

SKILLS—cont'd

CRITICAL THINKING CONNECTION Clinical Assignment

It can be alarming to see a patient struggle to breathe or to have to assist a patient who must be suctioned to be able to breathe. As the patient becomes more anxious, it is easy for your anxiety to increase as well. This chapter will help you prepare to care for patients who have respiratory prob- lems, assisting them to improve oxygenation and breathe more easily. NORMAL OXYGENATION The term airway refers to the path that air takes as it enters and exits the lungs. The normal pathway is through the nos- trils into the pharynx, into the trachea, and then to either the right or the left bronchus, which branches into the bron- chioles that terminate into the alveoli. When this pathway is unblocked and air is moving freely, it is referred to as a patent airway. The Mechanics of Breathing When the airway is patent, air is inhaled and follows the pathway to the alveoli, where oxygen is absorbed into the blood and carbon dioxide leaves the blood to be exhaled. You are assigned to care for a hospitalized patient tomor- row in clinical who has a tracheostomy. He was injured in a car accident and was on a ventilator for several weeks. He is breathing on his own now, but he still has the trache- ostomy in place. In addition, he has recently developed pneumonia in his right lung. He has a large amount of secretions and requires suctioning every 2 to 3 hours. The tracheostomy will have to be cleaned on your shift and a new inner cannula put in place. He has humidified oxygen at 4 L/min via a tracheostomy collar. Critical Thinking Questions 1. Why is a tracheostomy done? 2. How does a tracheostomy work? 3. How will you suction it? 4. How will you clean it and replace the inner cannula? 5. What is a tracheostomy collar?

• WORD • BUILDING • inhalation: in – in + hala – breath + tion – action exhalation: ex – out + hala – breath + tion – action

UNIT FOUR

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Clinical Skills and Care

trapping carbon dioxide in your blood, causing a buildup of carbonic acid, which in turn prompts the medulla to make you breathe. REGULATION OF RESPIRATION IN CHRONIC LUNG DISEASE. People who have severe chronic lung disease grad- ually develop a different stimulus to breathe. Unlike the sit- uation in persons with healthy lung tissue, in people with severe chronic lung disease, air is trapped in the alveoli for long periods because oxygen and carbon dioxide are unable to diffuse freely across the stiff, nonelastic alveolar mem- brane. This raises the blood’s level of carbon dioxide and lowers the oxygen level. The body gradually acclimates to the higher carbon dioxide level because it cannot continue to increase the respiratory rate higher and higher to blow it off. Thus the high carbon dioxide level no longer stimulates res- piration, and the body begins to respond to the lower level of oxygen, which now becomes its stimulus to breathe. Then, in some situations, high levels of supplemental oxygen can impair the message from the medulla that instructs the body to breathe. It will be important to remember this later in the chapter when we discuss oxygen fl ow rates for patients with chronic lung disease. Internal and External Respiration External respiration occurs between the alveoli and the capillaries. The alveoli are air sacs encircled by tiny capil- laries. Oxygen moves via diffusion from an area of higher concentration to an area of lower concentration. When you inhale, the inspired air contains more oxygen, so it passes from the alveoli into the capillaries. Internal respiration occurs between the bloodstream and the body cells. When fresh oxygen enters the bloodstream, it is carried by the hemoglobin on the red blood cells through the arteries and arterioles to the capillaries. In the tiny cap- illaries, where the walls are just one cell thick, the oxygen diffuses to the tissue cells where the concentration is lower. At the same time, carbon dioxide and other waste products diffuse into the blood from the tissue cells for the same rea- son. The blood then returns to the heart and lungs through the venules and veins. Once the blood is pumped back to the lungs by the right side of the heart, the carbon dioxide and waste products leave the blood and enter the alveoli to leave the body with exhalation. Anatomy and Physiology Connection The Pleura The chest cavity is lined with a thin membrane that also covers each lung, similar to a sac within a sac. This membrane is called the pleura. The portion of the pleura that lines the chest cavity is called the parietal pleura. This continuous membrane then covers the lungs, and that portion is called the visceral pleura. There is a very narrow space between the two layers, referred to as the

pleural space, in which a negative pressure, or vacuum, must be maintained so that expansion of the chest wall will cause the lung to expand as the chest wall expands. If this vacuum is lost and air or fluid enters into the pleural space, the lung will collapse rather than expand. This space contains a small amount of fluid that helps hold the two layers together but also allows them to glide smoothly against one another with each inhalation and exhalation. A similar situation occurs when you add a drop of water to a microscope slide, then place the coverslip over it. The water forms a film that holds the coverslip on the slide but allows it to glide against the slide for correct placement.

KNOWLEDGE CONNECTION What role do muscles, nerves, and chemicals play in respi- ration? What are the similarities and differences between internal and external respiration?

IMPAIRED OXYGENATION If a blockage occurs in the airway or oxygen cannot pass into the blood in the alveolar capillaries, the patient is unable to obtain needed oxygen from room air. If oxygen cannot cross into the tissue cells in the peripheral capillaries, the patient is unable to provide oxygen to body cells. Each of these situations can lead to impaired oxygenation. It is very important to recognize the signs and symp- toms of decreased oxygen in the blood and tissues because oxygen is necessary for brain and organ function. Often the symptoms do not become noticeable until the oxygen level has dropped considerably. When oxygen levels in the blood drop below normal range, it is referred to as hypoxemia. In the event of hypox- emia, the blood cannot take adequate amounts of oxygen to the tissues during internal respiration, causing hypoxia. Without enough oxygen in the tissues, you will see changes in mental function, in the color of the skin and mucous mem- branes, and in respiratory rate and rhythm. Box 28.1 lists the signs and symptoms of hypoxia. • WORD • BUILDING • parietal pleura: parietal – forming wall of a cavity; pleura – pleural membrane visceral pleura: visceral – body organs; pleura – pleural membranes hypoxemia: hypo – deficient + ox – oxygen + em – blood + ia – condition hypoxia: hypo – deficient + ox – oxygen + ia – condition

Chapter 28

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Another cause of impaired oxygenation may be secre- tions in the alveoli or damage to the alveoli caused by chronic lung disease. When the alveoli are not fully func- tional, less oxygen can cross into the blood and less carbon dioxide is able to leave the blood. Low oxygen in the blood may also be caused by a situation in which the patient is unable to fully expand the lungs because of fl uid or pus in the chest cavity or a blood clot in the lung preventing circu- lation to the alveoli. Patients who have had surgery or chest trauma may have hypoxemia caused by pain that prevents them from taking a deep breath. Chronic lung disease is also a cause of hypoxemia. Over time, the alveoli and airways are damaged, making them unable to expand and move air in and out, so oxygen does not cross into the alveolar capillaries to be taken to the body tissues. Damage or trauma to the lung itself also can cause hypox- emia. If a lung collapses, called atelectasis, expansion does not occur, so air is not pulled into the lungs. This may be the result of trauma such as a bullet or knife wound to the chest. It also may be caused by blockage of the airway to the lung, preventing expansion of the lung. For example, if a large tumor is blocking the air path in the right main bronchus, inhaled air is unable to fi ll the lung. Be aware that a patient can have a normal pulse oximetry reading and still suffer from hypoxia. If the blood is carry- ing adequate amounts of oxygen, the pulse oximetry reading will be normal. However, the oxygen may not be crossing the capillary wall and entering the tissue cells. Box 28.2 summa-

Box 28.1 Signs and Symptoms of Hypoxia

When patients become hypoxic, the early symptoms may be missed if you are not aware of them. By the time the later symptoms are evident, the patient is severely hypoxic. It is important to assess your patients for the early subtle signs and the more apparent ones.

Early • Agitation • Anxiety • Changes in level of consciousness • Disorientation

• Headache • Irritability • Restlessness • Tachypnea

Late • Bradycardia • Cardiac arrhythmias • Cyanosis • Decreased respiratory rate (bradypnea) • Retractions

Real-World Connection Effects of Hypoxia on Thinking

rizes the causes of hypoxia and hypoxemia. Caring for Patients With Impaired Oxygenation

Hypoxia to the brain can cause changes in mental function, including affecting judgment. A home health nurse went to visit a patient with chronic lung disease who had recently been hospitalized with respiratory failure. When the nurse arrived, she found that the patient had recently discharged his gun in his home. He had seen his reflection in a mirror, and his hypoxic brain had misinterpreted the face as that of a stranger; he thought that someone was looking in the window of his home. After discharging the gun, he realized that he had shot at his own reflection. His oxygen saturation was very low at 66%, and he was readmitted to the hospital. Causes of Impaired Oxygenation A variety of situations can contribute to impaired oxygen exchange. It may be the result of some type of obstruction in the pharynx, trachea, or bronchi causing a decrease in inspired air. If the nose is blocked because of mucus congestion, the body uses an alternative path and mouth breathing occurs. If the trachea is blocked by secretions, coughing clears them. If the trachea becomes blocked by a foreign body, such as a piece of food, and coughing is either impossible or not suf- fi cient to remove the blockage, the Heimlich maneuver can be performed to clear the airway. If the bronchi or bronchi- oles are blocked by thick mucus or secretions, deep coughs and possibly mucus-thinning agents are required to clear it.

You will care for many patients with impaired oxygenation. Generally, these patients are anxious and frightened; being unable to get your breath is a terrifying experience. As the patient’s nurse, it is very important for you to remain calm.

Box 28.2 Causes of Hypoxia and Hypoxemia

A variety of conditions can lead to hypoxia and hypoxemia. These may be caused by a mechanical problem that interferes with air entering the body, blood conditions interfering with the blood’s ability to transport oxygen, side effects of medications, or environmental situations. Causes include the following: • Airway obstruction caused by a tumor, choking on a foreign body, thick mucus, or swollen airways • Anemia • Atelectasis (collapsed lung) • Chronic lung disease • Decreased cardiac output • High altitude • Hypoventilation caused by anesthetics, sedatives, or coma • Poor peripheral circulation • Pulmonary embolus

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